Coastal Plain Area Eoa, Inc

COASTAL PLAIN AREA EOA, INC.

Employment Application

Personal Information
Name (Last, First, MI)
Street address
City, State, and Zip Code
Telephone / Alternate Phone / Email Address
Employment Desired
Position applied for: Teacher Teacher Assistant Substitute Teacher
 Family Health Advocate Center Supervisor CDL Bus Driver
Floater Cook Custodian
Other: ______
How did you hear about this position?
I am seeking a: / Full-time job / Part-time job / Full or Part-time
How many hours can you work weekly? / Date available for work?
Skills
Identify formal job training:
(Check all that apply) /  Teacher  Substitute Teacher
 Teacher Assistant  Paraprofessional
 Child Care Provider (i.e., day care center, in-home, etc.)
 Other (describe) ______
 Other (describe) ______

Identify what skills or certification you possess: (Check all that apply)

/  Microsoft Word  Typing ______wpm
 Microsoft Excel  Microsoft Outlook
 Other (describe) ______
 Other (describe) ______

List any professional, trade, business or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, national origin, ancestry, age, disability or any other protected status.

List any languages other than English that you speak, read or write that could be of benefit to the position applied for:
Fluent / Good / Fair
Speak
Read
Write

Additional Information

Have you ever been employed by this organization in the past?

/

 Yes

/

 No

Do you have any friends or relatives employed by this company?

If Yes, please provide their names and relationship to you: /

 Yes

/

 No

I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States.

/

 Yes

/

 No

If you are under 18 years of age, can you provide proof of your eligibility to work?

/

 Yes

/

 No

Have you been convicted of a felony?  Yes No

If yes, explain:
Education
Name and Address of School / Years
Completed / Major / Degree or
Diploma
High
School /  HS Diploma
 GED
Undergraduate
College /  AA  AAS
 AS  AECE
 ABS AOS
 Other: ______
Graduate/
Professional /  BA BS
 MA MS
 Other: ______
Business/
Technical /  CDA
 Other:______
 Other: ______
Have you completed any Early Childhood Education courses?  Yes  No / If yes, how many?______
List any seminars, classes or other education not listed above which may help qualify you for this position
Employment History
List below all present and past employers over the past ten (10) years, starting with your most recent employer. Account for all periods of unemployment. You must complete this section even if attaching a resume. (All Fields Require Information; No Blanks)
May we contact your current employer? YES NO
1. / Employer (current Yes No) / Start
Date / End
Date / Essential job functions of final position
Address / 1.
City, State, Zip / Starting
Salary / Ending
Salary / 2.
Phone number / 3.
Fax number / Supervisor(s) / 4.
Job position(s) / E-mail address of supervisor
Reason(s) for leaving
May we contact this employer?  Yes  No
2. / Employer / StartDate / End

Date

/ Essential job functions of final position
Address / 1.
City, State, Zip / StartingSalary / EndingSalary / 2.
Phone number / 3.
Fax number / Supervisor(s) / 4.
Job position(s) / E-mail address of supervisor
Reason(s) for leaving
May we contact this employer?  Yes  No
3. / Employer / Start
Date / End
Date / Essential job functions of final position
Address / 1.
City, State, Zip / Starting
Salary / Ending
Salary / 2.
Phone number / 3.
Fax number / Supervisor(s) / 4.
Job position(s) / E-mail address of supervisor
Reason(s) for leaving
May we contact this employer?  Yes  No
4. / Employer / StartDate / End

Date

/ Essential job functions of final position
Address / 1.
City, State, Zip / StartingSalary / EndingSalary / 2.
Phone number / 3.
Fax number / Supervisor(s) / 4.
Job position(s) / E-mail address of supervisor
Reason(s) for leaving
May we contact this employer?  Yes  No
5. / Employer / Start
Date / End
Date / Essential job functions of final position
Address / 1.
City, State, Zip / Starting
Salary / Ending
Salary / 2.
Phone number / 3.
Fax number / Supervisor / 4.
Job position(s) / E-mail address of supervisor
Reason(s) for leaving
May we contact this employer?  Yes  No
6. / Employer / StartDate / End

Date

/ Essential job functions of final position
Address / 1.
City, State, Zip / StartingSalary / EndingSalary / 2.
Phone number / 3.
Fax number / Supervisor / 4.
Job position(s) / E-mail address of supervisor
Reason(s) for leaving
References
List below three persons not related to you who have knowledge of your work performance within the last 5 years
Name / Occupation
Company name / Address
Telephone / E-mail / Relationship & years acquainted
Name / Occupation
Company name / Address
Telephone / E-mail / Relationship & years acquainted
Name / Occupation
Company name / Address
Telephone / E-mail / Relationship & years acquainted
Questionnaire

1. If you are hired, what value would you add to Coastal Plain Area EOA, Inc.?

1. What are the most unique features of your work history?

APPLICANT'S CERTIFICATION AND AGREEMENT

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Coastal Plain Area Economic Opportunity Authority, Inc. to verify their accuracy and to obtain reference information on my work performance. I hereby release Coastal Plain Area Economic Opportunity Authority, Inc. from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Employer. However,

I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract.

 I agree to the above Applicant’s Certification and Agreement. Date: ______

- 1-